A Narrative Review on the Clinical Relevance of Imaging the Circumventricular Brain Organs and Performing Their Anatomical and Histopathological Examination in Acute and Postacute COVID-19.

ABSTRACT: Autopsy followed by histopathological examination is foundational in clinical and forensic medicine for discovering and understanding pathological changes in disease, their underlying processes, and cause of death. Imaging technology has become increasingly important for advancing clinical research and practice, given its noninvasive, in vivo and ex vivo applicability. Medical and forensic autopsy can benefit greatly from advances in imaging technology that lead toward minimally invasive, whole-brain virtual autopsy. Brain autopsy followed by histopathological examination is still the hallmark for understanding disease and a fundamental modus operandi in forensic pathology and forensic medicine, despite the fact that its practice has become progressively less frequent in medical settings. This situation is especially relevant with respect to new diseases such as COVID-19 caused by the SARS-CoV-2 virus, for which our neuroanatomical knowledge is sparse. In this narrative review, we show that ad hoc clinical autopsies and histopathological analyses combined with neuroimaging of the principal circumventricular organs are critical to gaining insight into the reconstruction of the pathophysiological mechanisms and the explanation of cause of death (ie, atrium mortis) related to the cardiovascular effects of SARS-CoV-2 infection in forensic and clinical medicine.

Micro-CT in a forensic examination of a fatal child abuse case: A case report.

Child abuse is a serious concern that can cause the death of a child. In such cases the medico-legal evidence is often pivotal but complex, drawing across multiple medical disciplines and techniques. One key specialism is histopathology, which is considered the gold standard for estimating the age of individual fractures. Another is micro-CT imaging, which can visualise the location of trauma across the body. This case report demonstrates how micro-CT was used to contextualise the histological evidence in the Criminal Justice Proceedings of a fatal child abuse case. This was achieved by overlaying the aged fracture evidence from histopathology onto the visuals rendered from micro-CT imaging. The case was a suspected child abuse of a deceased 1-month old infant who was reported unresponsive by their parents. The child was taken to hospital where they were pronounced dead. Suspicion was raised and post-mortem imaging confirmed head trauma and rib fractures, and the case was escalated for a forensic investigation. This case report details how the micro-CT imaging was merged with the gold standard of histopathology for visualisation of trauma, and how the court presentation was planned alongside Senior Investigating Officers and various medical experts. The presentation was used in court by the histopathologist to present the evidence. The resulting presentation provided additional clarity to jury members regarding the location, severity, frequency, and timings of the injuries. From the perspective of the investigating police force, the resulting presentation was crucial in ensuring understanding of the medico-legal evidence of how the infant died. The prosecuting lawyer noted that combining the histological and micro-CT evidence in this way allowed the evidence to be presented in a sensitive, clear, and impactful manner.

Estimation of the post-mortem interval; added value of mechanical excitability of human skeletal muscle.

Estimation of the post-mortem interval (PMI) is mainly based on the state of body cooling, post-mortem lividity (livor mortis) and post-mortem muscle stiffness (rigor mortis). However, the time span of development of these post-mortem phenomena are influenced by a variety of factors concerning the body of the deceased and the environment in which the body is found. Subsequently, this leads to a substantial spread in upper and lower limits of PMI based on determination of the state of these phenomena. Moreover, interpretation of post-mortem phenomena like lividity, rigor and interpretation of the correction factor for Henssge's nomogram is subjective. For this reason, PMI estimations are often broad, possibly too broad to be helpful for answering questions which are relevant for the criminal investigation. Therefore, combining the outcome of different methods for estimating the PMI, the so-called compound method, is recommended. Supravital muscle reaction by mechanical stimulation of skeletal muscle is a less known aspect of the compound method. Here we present a series of cases series in which supravital muscle reaction contributed to a more precise estimation of the PMI.

Singular stab wounds to the trunk: Is this suicidal or homicidal?

Differentiating homicidal or suicidal deaths in presence of a singular stab wound to the anterior or lateral trunk is still a challenge in forensic practice. There are numerous criteria in the literature and in current forensic textbooks to distinguish between self-inflicted injuries and homicide. The applicability of these criteria in single stab injuries was examined by elucidating 12 suicides and 33 homicides, each with a single stab injury to the anterior or lateral trunk and were largely confirmed. An instrumentality still stuck in the corpse was always associated with a suicide in the given cohort. In summary, the final evaluation should always be based on an interpretation of the post mortem findings together with the circumstances on site of discovery as well as the results of the police investigation.

Lethal hemopericardium caused by infection of mitral annular calcification: An autopsy case report.

Mitral annular calcification (MAC) is a chronic and degenerative condition involving calcification of the mitral annulus. MAC is a risk factor for coronary artery disease, cardiovascular events, stroke, and cardiovascular death. However, patients with MAC are often asymptomatic. Herein, we present the first case of cardiac tamponade due to infection of MAC in forensic pathology. An 80-year-old woman was found in cardiopulmonary arrest shortly after experiencing fatigue. She was transferred to a hospital, and despite chest compression and ventilation, she was pronounced dead due to no response. Postmortem computed tomography, autopsy, and histological examination showed MAC, abscess formation involving Gram-positive cocci on the MAC, and fistulation of the abscess into the intracardial pericardial cavities, resulting in a massive lethal hemopericardium.

Reliability in distinguishing murder from accidental event with current forensic criteria in traumatic head injury.

Discovering a body displaying signs of multiple head trauma requires a thorough examination by the forensic pathologist, and a multidisciplinary approach is recommended. However, determining the manner of death is not always possible. We present a case in which the body of a 60-year-old man was discovered lying face down on the floor of his apartment, partially unclothed, surrounded by blood and vomit, and presenting numerous head injuries. The autopsy concluded that the cause of death was a result of post-traumatic brain injury. Nevertheless, applying current criteria made it challenging to ascertain whether the trauma stemmed from an accidental event or an assault.

Homicidio por combinación de métodos de asfixia / Homicide by combination of methods of asphyxiation

Introducción el homicidio por combinación de métodos de asfixia se observa mayoritariamente en las personas de edad avanzada o con algún impedimento físico capaz de contrarrestar la agresión. Material y métodos se realizó un estudio observacional retrospectivo sobre 634 autopsias, cinco cumplían las características de homicidios por combinación de métodos de asfixia. Resultados dos hombres y 3 mujeres, con edad promedio de 69 años, con estudios toxicológicos negativos, víctimas de un solo agresor, presentaron lesiones cutáneas periorificiales (bucales y nasales), hemorragias musculares en el tórax, fracturas costales, lesiones contusas en la cabeza, interpretadas como de sometimiento. Discusión en la combinación de métodos de asfixia, los hallazgos que deben ser vistos en conjunto son: traumatismos craneoencefálicos para someter a la víctima, lesiones cutáneas en el cuello, la cara, la cara interna de los labios, fracturas costales y lesiones por contrapresión en la espalda, los glúteos o los codos. Contextualizados en conjunto pueden explicar la dinámica de esta modalidad homicida. (AU)

Introduction Homicide by combination of suffocation methods is observed mainly in elderly people or with some physical impediment capable of counteracting the aggression. Material and methods A retrospective observational study was carried out on 634 autopsies. Five met the characteristics of homicides by combination of asphyxiation methods. Results Two men and three women, average age 69 years, with negative toxicological studies, victims of a single aggressor, presented peri orificial skin lesions (mouth and nose), muscle hemorrhages in the thorax, rib fractures, blunt injuries to the head interpreted as like submission. Discussion In the combination of asphyxia methods the findings that must be seen together: Head injuries to subdue the victim, skin lesions on the neck, face, inner face of the lips, rib fractures, and counter-pressure injuries to the back, buttocks, or elbows. Contextualized together, can explain the dynamics of this homicidal modality. (AU)

Postmortem Computed Tomography Is a Reliable, Reproducible, and Accurate Method in Measuring Body Length.

ABSTRACT: Currently, traditional body length measurement at postmortem analysis involves processes, which are susceptible to human error and not reviewable or reproducible in case of data loss. Many facilities are now adopting routine postmortem computed tomography (PMCT) scanning, which provides a permanent and reviewable radiological record of body dimensions. Previous literature has validated the use of PMCT in estimating body and organ weights, but not in body length measurement. This retrospective study aimed to determine whether body length can be accurately and reliably measured when compared with traditional measurements in 50 consecutive adult cases. Our findings revealed that body length measured using PMCT had high intrarater and interrater reliability across different experience levels in raters (Pearson correlation coefficient and interclass correlation: >0.99, P < 0.01). Although body lengths measured using PMCT were significantly shorter (mean, -1.2 cm; 95% confidence interval, -1.75 to -0.65 cm; P < 0.05), it was deemed clinically insignificant and correlated well with those measured at postmortem examination (Pearson correlation coefficient and interclass correlation, >0.97; P < 0.01). While care will need to be taken to ensure the body in the body bag is in reasonable anatomical position for scanning purposes, overall, body length measured uniform PMCT is reliable, reproducible, and accurate.

The grading diagnostic strategy of molecular autopsy combined with pathological autopsy in the forensic diagnosis of cardiomyopathy.

The diagnosis of cardiomyopathy often relies on the subjective judgment of pathologists due to the variety of morphologic changes in the condition and its low specificity. This uncertainty can contribute to unexplained sudden cardiac deaths (USCD). To enhance the accuracy of hereditary cardiomyopathy diagnosis in forensic medicine, we proposed a combination of molecular autopsy and pathologic autopsy. By analyzing 16 deceased patients suspected of cardiomyopathy, using whole exome sequencing (WES) in molecular autopsy, and applying a combined diagnostic strategy, the study found pathogenic or likely pathogenic variants in 6 cases. Out of the 16 cases, cardiomyopathy was confirmed in 3, while 3 exhibited conditions consistent with it. Data for 4 cases was inconclusive, and cardiomyopathy was ruled out in 6. Notably, a novel variant of the TTN gene was identified. This research suggests that a grading diagnostic strategy, combining molecular and pathological evidence, can improve the accuracy of forensic cardiomyopathy diagnosis. This approach provides a practical model and strategy for precise forensic cause-of-death determination, addressing the limitations of relying solely on morphologic assessments in cardiomyopathy cases, and integrating genetic information for a more comprehensive diagnosis.

A comparative assessment of time-consuming and laborious diatom analysis：Brief experimentation with suggestion of automatic identification.

Diatom testing is considered a useful method for providing supportive evidence for the diagnosis of drowning in forensic pathology. However, various factors remain controversial for recognizing diatoms, such as being time-consuming and laborious and influencing the consistency of the results. Given the absence of precise and well-defined studies on this subject, this study aimed to determine the relationship between the ability to identify diatoms and researchers with different technical backgrounds. A total of 55 samples from 18 cases, including water, lungs, liver, and kidneys, were treated using the microwave digestion-vacuum filtration-automated scanning electron microscopy (MD-VF-Auto SEM), which was used to compare diatom analyses among three groups of well-trained forensic pathologists (FPs), trained junior employees (JEs), and new trainees (TEs). In addition to achieving similar accuracy of positive findings from drowning cases, counting efficiency was evaluated based on taxonomy records and counting time after viewing more than 5500 diatom images. In contrast to the higher counting efficiency of the JE group than that of the TE group, we observed a statistically significant difference (p < 0.05) in the diatom classification between these two groups. Based on our experiments, an efficient analysis for automatically identifying and classifying diatoms is urgently required.

The relationship between postmortem interval and protein changes in mice.

Postmortem interval (PMI) estimation is important for forensic pathological autopsy. It has been reported that there is a correlation between certain protein changes in cadavers and PMI. However, no specific protein(s) has been used to determine the PMI so far. In this study, the total protein contents of mouse liver and spleen at different time of death were measured. The data showed that they were negatively correlated with the PMI. The degradation of ß-actin was found to be positively correlated with the PMI in the liver. Additionally, proteomic technique was used to study the changes of protein expression related to PMI in the liver of mice. By using Two-dimensional electrophoresis, the expressions of four proteins were found to be significantly decreased and those of other three proteins were unchanged with the increase of PMI. Among the seven proteins, six were identified with peptide mass fingerprinting using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. The three altered proteins were SBP2, ENOA, ALDH2 and three unchanged ones were 3HAO, TPIS, CATA, respectively. In the future, those unchanged proteins could be used as internal references to more accurately and reliably infer the time of death by assessing the level of changed proteins.

Luminol and the postmortem interval estimation - influence of taphonomic factors.

The estimation of the postmortem interval (PMI) is one of the key challenges for forensic anthropologists. Although there are several methods referenced for this purpose, none is sufficiently effective. One of the main reasons justifying the complexity of this task is the influence of several taphonomic factors.The study of the Luminol technique has stood out as a promising method for estimating PMI, complementing the existing methods, since it is an economic, easy and reproducible method that operates as a presumptive test. However, it is not known which taphonomic factors can influence the results obtained by this technique.The aim of this study is to test the influence of taphonomic factors, such as temperature, humidity, soil type and pH, on the estimation of the PMI by the Luminol technique.In order to test the influence of the referred factors, a sample consisting of 30 clavicles, with known and similar PMI, collected from autopsies, was distributed as evenly as possible by six vases and buried with different decomposition conditions for a period of 12 months. After the exhumation and sample preparation, the Luminol technique was applied.It was possible to clearly observe differences in the results. Thus, according to our research, it is possible to conclude that the results obtained by the application of Luminol are influenced by taphonomic factors. Therefore, the context in which a body is found should always be considered for applying this technique.

Bone and Tooth: Substrates for determining Drowning: A new diagnostic procedure in forensic medicine Practice?

INTRODUCTION: Diatom tests are rarely used during autopsy to confirm drowning as the cause of death (COD) because of limitations of the current literature involving these techniques. Instead, experts rely on physical examination by the pathologist. Due to interpretive concerns regarding Diatom tests, they are often insufficient in establishing a diagnosis, but offer the potential to be an extremely useful diagnostic tool with further understanding. The aim of study is to optimize "Diatom Tests" for use in forensic medicine in Bosnia and Herzegovina. METHODS: A randomized prospective experimental study was conducted, using albino Wistar rat models (Rattus norvegicus), at the Veterinary Facility, University of Sarajevo. Thirty-two adult albino rats, were used and distributed into groups as follows: Group A (6 deceased rats with COD other than drowning, but due to mechanical asphyxia, which were then submerged for 1 h after death); Group B (6 deceased rats with COD other than drowning, but due to mechanical asphyxia, which were then submerged for 72 h after death); Group C (6 rats that were immediately autopsied after drowning, with COD determined as drowning); Group D (6 rats that underwent a 48-hour postmortem period after drowning); Group E (COD: drowning, post-mortem 72hrs after death, remained submerged in water until PM). Live algological material was collected for the research of the systematics of algae from the Bosna river, Sarajevo, and transported to the University of Sarajevo (Department of Biology, Faculty of Science). Periphyllon, epiphyllon and epipelon were used to collect phytobenthos. The material was fixed with 4% formalin solution. Laboratory processing of diatoms was performed using the methods described by Hustedt (16). In the process of obtaining pure diatom valves, part of the material is digested with potassium permanganate (KMnO4), sulfuric acid (H2SO4), and oxalic acid (C2H2O4). In the next step, the cleaned diatom valves were mounted in Canadian balsam. A light microscope under 1000x magnification (Best Scope 2020) was used to evaluate and analyze the species. The identification of diatoms was performed using the reference of Cantonati et al (17). The nomenclature of diatom species was performed according to Guiry & Guiry's worldwide electronic internet database. RESULTS: No diatoms were found in Groups A and B. However, Navicula sp. and Sellaphora sp. cf., were discovered during bone analysis of Group C where rats were immediately autopsied after drowning. Hantzschia amphioxus taxon was present in Group D, which underwent a 48-hour postmortem period after drowning and before samples were taken. In Groups C and D, where drowning was the COD, Diatoma vulgaris i Pinnularia major, Achnanthidium minutissimum i Melosira varians were present in the tooth samples. CONCLUSION: Optimization of the "Diatom Test" method could potentially lead to its future use as a routine method within experimental settings. This experimental study is a starting point that guides forenscic medicine pracitioners towards the optimization of tests and sampling in cases of unexplained etiology, where preserved soft tissue structures is not available. In these cases, teeth and bones serve as accessible materials for diagnosing COD, alongside standardized nonspecific findings in the absence of organs for micro- and macroanalysis.

Impact of changing from autopsy to post-mortem CT in an entire HM Coroner region due to a shortage of available pathologists.

A significant problem facing routine medicolegal coroner-referred autopsies is a shortfall of pathologists prepared to perform them. This was particularly acute in Lancashire, where the coroner decided to initiate a service that relied on post-mortem computed tomography (PMCT). This involved training anatomical pathology technologists (APTs) to perform external examinations, radiographers to perform scans, and radiologists to interpret them. The service started in 2018 and now examines over 1,500 cases per year. This study outlines the PMCT process using NHS staff, with CT equipment and logistics managed by the commercial sector. It compares the demographics and outcomes of PM investigations for two 6-month periods: the autopsy service prior to 2018, and then the PMCT service. These data were then compared with previous UK PMCT data. Referrals for adult non-suspicious deaths were made in 913 cases of which 793 (87%) had PMCT between 01/10/2018 and 31/03/2019. Fifty-six cases had autopsy after PMCT, so 81% of cases potentially avoided autopsy. The PMCT service did not delay release of bodies to the next-of-kin. Comparing the cause of death given shows no difference in the proportions of natural and unnatural deaths. There was an increase in diagnosis of coronary artery disease for PMCT, with less respiratory diagnoses, a feature not previously demonstrated. These data suggest PMCT is a practical solution for potentially failing autopsy services. By necessity, this involves changes in diagnoses, as PMCT and autopsy have different strengths and weakness, but the ability to pick up unnatural death appears unaffected.

Post-mortem CT in the investigation of homicides.

AIM: To investigate the reliability of post-mortem computed tomography (PMCT) in a case series of homicides involving blunt-force, sharp-force, and ballistic trauma. MATERIALS AND METHODS: The study investigates 16 homicide cases that underwent PMCT before autopsy. Two radiologists assessed the PMCT examinations and the data were compared to the forensic pathology findings. Data were organised in broad categories: foreign bodies, external injuries, soft-tissue and organ injuries, fractures, air in cavities, fluid collections, random pathology, and wound track. Findings were organised by systems: head and neck, thorax, abdomen and pelvis, extremities. Cohen's kappa statistics were used to assess observer agreement. RESULTS: Six gunshot-related homicides (37.5%), seven sharp-force-related homicides (43.75%), two blunt-force-related deaths (12.5%), and one homicide due to mechanical asphyxia (1.25%) were analysed. A total of 64 fractures were reported by the pathologists, 67 by radiologist 1 and 68 by radiologist 2. Agreement was deemed substantial in all cases. Pathologists failed to report gas in cavities while radiologists underreported superficial injuries. CONCLUSION: An overall observation was that less accurate findings were produced by the blinded radiologist in comparison to the non-blinded one. The extremeness of homicides obscured the interpretation of PMCT leading to the observed discrepancies. The combination of PMCT and autopsies is deemed optimal when investigating homicidal events.